Ceremonial or Sacred Use
S1. Do you use tobacco for ceremonial prayer or traditional reasons?
Yes £1
No £2 (go to Brand Smoked section)
Don’t know/Not sure £7
Refused £9
S2. When you used tobacco for ceremonial or prayer or traditional reasons, what type of tobacco did you use? (Choose all that apply)
Native Tobacco £1
Commercial tobacco such as Marlboro, GCP, etc. £2
Don’t know/Not sure £7
Refused £9
S3. Have you ever smoked a pipe for ceremonial prayer or traditional reasons?
Yes £1
No £2 (go to Brand Smoked section)
Don’t know/Not sure £7
Refused £9
S4. When you smoked a pipe for ceremonial prayer or traditional reasons, what type of tobacco did you use? (Choose all the apply)
Native tobacco £1
Commercial tobacco such as
Marlboro, GCP, etc £2
Other (Specify) ______£3
Don’t know/Not sure £7
Refused £9
Brand Smoked
S5. What brand of cigarettes do you smoke most often? (MARK ONLY ONE)
Natural American Spirit ££01
Benson & Hedges ££02
Camel ££03
Carlton ££04
Generic ££05
Geronimo ££06
Kent ££07
Kool ££08
Lucky Strike ££09
Marlboro ££10
Merit ££11
More ££12
Native Brand ££13
Newport ££14
Noble ££15
Omaha Brand ££16
Pall Mall ££17
Salem ££18
Santa Fe ££19
Seneca Brand ££20
Virginia Slims ££21
Other (specify) ______££22
Don’t know/Not sure ££77
Refused ££99
Participant Does not smoke ££100
Asthma
S6. Have you ever been told by a doctor, nurse or other health professional that you had asthma?
Yes £1
No £2 (go to Alcohol section)
Don’t know/Not sure £7
Refused £9
S7. Do you still have asthma?
Yes £1
No £2
Don’t know/Not sure £7
Refused £9
BF1. How old were you when you were first told by a doctor, nurse, or other health professional that you had asthma?
Age in years [76 = 76 and older] _ _ 1-76
Don’t know/Not sure ££77
Refused ££99
BF2. Symptoms of asthma include cough, wheezing, shortness of breath, chest tightness and phlegm production when you don’t have a cold or respiratory infection. During the past 30 days, how often did you have any symptoms of asthma? Would you say —
Not at any time ……………………………………………………………..£1
Less than once a week ………………………………………………….£2
Once or twice a week ………………………………………………….…£3
More than 2 times a week, but not every day ……………..£4
Every day, but not all the time ……………………………………..£5
Or
Every day, all the time …………………………………………………..£6
Don’t know / Not sure …………………………………………………..£77
Refused ……………………………………………………….£99
BF3. During the past 12 months, how many times did you visit an emergency room or urgent care center because of your asthma?
Number of visits __ __ [76 =76 or more]
Don’t know/Not sure ……………………………………………………..£77
Refused…………………………………………………………………………..£99
Alcohol Consumption
BF4 During the past 30 days, have you had at least one drink of any alcoholic beverage such as beer, wine, a malt beverage or liquor?
Yes £1
No £2 (go to diabetes section)
Don’t know/Not sure £7
Refused £9
BF5 During the past 30 days, how many days per week or per month did you have at least one drink of any alcoholic beverage?
Days per week………………………... __ __
Days in past 30 days ……………… __ __
No drinks in past 30 days ……. £3
Don’t know / Not sure …………… £88
Refused …………………………………..£99
Read:
One drink is equivalent to a 12-ounce beer, a 5-ounce glass of wine, or a drink with one shot of liquor.
Note: A 40 ounce beer would count as 3 drinks, or a cocktail drink with 2 shots would count as 2 drinks.
BF6 During the past 30 days, what is the largest number of drinks you had on any occasion?
Number of drinks…………………__ __
Don’t know / Not sure……………£88
Refused……………………………….£99
Diabetes
S8. Have you ever been told by a doctor, nurse, or other health professional that you have diabetes?
Yes, but I am female and was told this
only when I was pregnant £1
Yes £2
No £3
No, but I have been told that I am pre-diabetes
or border line £4
Don’t know/Not sure £7
Refused £9
Hypertension Awareness
S9. Have you ever been told by a doctor, nurse, or other health professional that you have high blood pressure?
Yes, but I am female and was told this
only when I was pregnant £1
Yes £2
No £3 (go to cholesterol section)
Don’t know/Not sure £7
Refused £9
S10. Are you currently taking medicine for your high blood pressure?
Yes £1
No £2
Don’t know/Not sure £7
Refused £9
Cholesterol Awareness
S11. Blood cholesterol is a fatty substance found in the blood. Have you ever had your cholesterol checked?
Yes £1
No £2 (go to Cardiovascular Disease section)
Don’t know/Not sure £7
Refused £9
S12. About how long has it been since you last had your blood cholesterol checked?
Within the past year (anytime less than
12 months ago) £1
Within the past 2 years (1 year but less than
2 years ago) £2
Within the past 5 years (2 years but less than
5 years ago) £2
5 or more years ago £4
Don’t know/Not sure £7
Refused £9
S13. Have you ever been told by a doctor, nurse, or other health professional that your blood cholesterol is high?
Yes £1
No £2
Don’t know/Not sure £7
Refused £9
Cardiovascular Disease/Stroke
S21a. Has a doctor, nurse or other health professional ever told you that you have had a heart attack, also called a myocardial infraction?
Yes £1
No £2 (go to coronary heart disease question)
Don’t know/Not sure £7
Refused £9
S21b. At what age did you have your first heart attack?
Age (76=76+) ££01-76
Don’t know/Not sure ££77
Refused ££99
S21c. Has a doctor, nurse, or other health professional ever told you that you have Angina or coronary heart disease?
Yes £1
No £2
Don’t know/Not sure £7
Refused £9
S21d. Has a doctor, nurse, or other health professional ever told you that you have had a stroke?
Yes £1
No £2 (go to pregnancy section)
Don’t know/Not sure £7
Refused £9
S21e. At what age did you have your first stroke?
Age (76=76+) ££01-76
Don’t know/Not sure ££77
Refused ££99
Pregnancy
S22. Have you ever been pregnant during your lifetime?
Male (do not ask) £1 (go to more demographics section)
Female No £2 (go to more demographics section)
Female Yes £3
S23. During any of your prenatal care visits, did a doctor, nurse, or health care worker talk with you about how smoking during pregnancy could affect your baby?
Yes £1
No £2
Don’t know/Not sure £7
Refused £9
S24. In the 3 months before you got pregnant, how many cigarettes did you smoke on an average day (pack = 20 cigarettes)?
None (0 cigarettes) £1
Less than 1 cigarette £2
1 to 5 cigarettes £3
6 to 10 cigarettes £4
11 to 20 cigarettes £5
21 to 40 cigarettes £6
41 cigarettes or more £7
Don’t know/Not sure £77
Refused £99
S25. In the last 3 months of your pregnancy, how many cigarettes did you smoke on an average day (pack = 20 cigarettes)?
None (0 cigarettes) £1
Less than 1 cigarette £2
1 to 5 cigarettes £3
6 to 10 cigarettes £4
11 to 20 cigarettes £5
21 to 40 cigarettes £6
41 cigarettes or more £7
Don’t know/Not sure £77
Refused £99
More Demographics
BF7 About how much do you weigh without shoes?
Weight ……………………. ______
(pounds)
Don’t know/Not sure £77
Refused £99
BF8 About how tall are you without shoes?
Height …………………….. ______
Feet Inches
Don’t know/Not sure £77
Refused £99
Opinions Regarding Tobacco Policy
AA1. Requiring worksites/ businesses to be smoke-free would save businesses money
Strongly Agree ……………………£1
Agree ………………………………….£2
Disagree …………………………….£3
Strongly Disagree ……………..£4
Don’t know/Not sure £77
Refused £99
AA2. Requiring worksites/ businesses to be smoke-free would cost businesses money
Strongly Agree ……………………£1
Agree ………………………………….£2
Disagree …………………………….£3
Strongly Disagree ……………..£4
Don’t know/Not sure £77
Refused £99
AA3. The tribal government has an obligation to protect public health, including restricting secondhand smoke exposure within tribal land boundaries.
Strongly Agree ……………………£1
Agree ………………………………….£2
Disagree …………………………….£3
Strongly Disagree ……………..£4
Don’t know/Not sure £77
Refused £99
AA4. People in my community have a good understanding about the health effects of tobacco use and secondhand smoke
Strongly Agree ……………………£1
Agree ………………………………….£2
Disagree …………………………….£3
Strongly Disagree ……………..£4
Don’t know/Not sure £77
Refused £99
AA5. How often do you see tobacco prevention advertisements, which are public services announcements promoting quitting, youth prevention, and smoke-free environments, on television, newspapers and billboards, radio messages in your community?
Frequently ……….…£1
Sometimes …..…….£2
Rarely ……..………….£3
Never ………………….£4
Don’t know/Not sure £77
Refused £99
AA6. How often do you see tobacco advertisements, which are advertisements promoting commercial tobacco products, in your community publications?
Frequently ……….…£1
Sometimes …..…….£2
Rarely ……..………….£3
Never ………………….£4
Don’t know/Not sure £77
Refused…………………………………………………………………….. £99